Delivering Better Care Per Dollar Spent: The musculoskeletal industry’s ability to drive forward value-based care
This year, perhaps more than ever, our health care system is revealing where it works, and a sobering view of where the system itself is unhealthy. Maybe we share a common reality these days: I write this sitting on a well-worn couch, next to my 5-year-old, while he watches what I know far exceeds the amount of television recommended by the American Association of Pediatrics. I am grateful for employment at a time many are without, yet I am slumped both emotionally and physically, with one arm around him as I awkwardly type. Fortunately for me, the onslaught of COVID-19 is the first time in middle age I have experienced back pain and I suddenly feel, amongst these aches and pains, deep empathy for the thousands of Americans with musculoskeletal issues that have been triggered by or far preceded this pandemic.
And evidently I’m not alone: 70% of employees on employer-sponsored health plans with musculoskeletal conditions report their pain has either gotten worse or they are experiencing new pain since remote work.¹
And that’s just the physical pain, not to mention the financial pain in receiving care within the United States health care system. For decades, health care costs have far outpaced inflation, and we have come to expect this. In 2020, we spent about $11,100 per person on health care, which is more than double the average spend in other developed countries.² Yet, as my colleague Natalie Privett explains, our outcomes lag. Each part of this complex system sees year-over-year financial gains when it comes to big data and predictive analytics, digital technology, care delivery, and finance — yet people aren’t getting any healthier.
Central to this are the perverse incentives that act as the system’s flywheel. We operate within what’s described as a fee-for-service model, which is to say we’ve been paying for care line by line, no matter the outcome. It would be like paying for each ingredient of a meal, with no guarantee that it will yield what you think — expect — you ordered. It’s a model that incents profit and margin over health outcomes, which can come disguised as tendencies to over-diagnose, and over-treat, but to no gain for our actual health.
We operate within what’s described as a fee-for-service model, which is to say we’ve been paying for care line by line, no matter the outcome. It would be like paying for each ingredient of a meal, with no guarantee that it will yield what you think — expect — you ordered.
So, how does this relate to my back pain?
A great deal. But first, some context:
Musculoskeletal conditions affect more than one in two adults³ — negatively impacting work productivity, physical and financial health, and quality of life. And they are the leading contributor to disability worldwide, with low back pain being the single leading cause of disability in 160 countries.⁴
It’s evident the quality of life is low. And the cost of treatment can be high, and climbing higher each day:
Costs of less-invasive procedures in outpatient surgery centers have tripled.⁵
… which sounds good, right? Except that ultimately, this leads to symptomatic treatment such as pain management, where, upon further investigation, a more appropriate care plan could be lifestyle changes, exercise or physical therapy. And for a far better price.
MRIs are in high demand.
While many musculoskeletal journeys may begin with an MRI, they are often a pathway to surgery.
Surgery is an expensive, invasive solution that’s not fit-for-size.⁶
- There are 5.2M annual operations, but only 5% are actually candidates. Full stop.The majority of patients receive surgery before considering more conservative options.
- For patients who end up having surgery, not all surgeries are created equal; surgeon-based choices about the type of surgery have a large impact on cost. Educating patients about more cost-effective treatment options, including various surgical options, should be a part of this approach — and as upstream as possible.
- Procedures and diagnostic imaging drive rising costs.
- Surgery risks unnecessary re-operation, as musculoskeletal surgeries lead to high re-operation rates and risks of infection.
- Surgery often does not provide better outcomes, but is too often turned to first.
Sometimes surgery is the most necessary care pathway. But how might we ensure that it is the right path, and not the first path?
This illustration is just one example of how an overly-aggressive, profit-driven health care system centered around acute and specialist care can often exacerbate pain both physically and financially for the very people it is intended to serve.
And musculoskeletal conditions are part and parcel of modern life. Most people, like me, will experience pain as they age (and, as noted above, these can be very expensive conditions). Musculoskeletal care costs now rank as the second largest source of health care expenditures — exceeding the costs of heart disease, cancer, or diabetes. Beyond the medical costs, many people and their employers experience added costs such as lost work days and absenteeism. Yet for some reason, musculoskeletal outcomes have not improved over the last decade. In fact, despite a 65% increase in health expenditures for patients with back and neck problems, there has not been a corresponding improvement in patient clinical outcomes data.⁷
Musculoskeletal care costs now rank as the second largest source of health care expenditures — exceeding the costs of heart disease, cancer, or diabetes.
This is where value-based care comes in.
Value-based care holds providers accountable for their clinical and financial outcomes, rewarding high performance. It disincentivizes waste, unnecessary or costly interventions, and poor quality care. But to deliver on this model requires a dramatic shift in approach, and innovation across both care delivery and administrative and financial models. Done well, it’s a radically better patient-centered model as it ensures people receive the right care at the right time, by the right provider. No more, no less.
…it ensures people receive the right care at the right time, by the right provider.
And value-based care is being put to practice by industry innovators. At the Design Institute for Health, we are honored to work with a remarkable care provider who has parted ways with the antiquated fee-for-service model to instead embrace value-based care.
UT Health Austin’s Musculoskeletal Institute diagnoses, treats, and manages musculoskeletal disorders, helping reduce pain, improve function, and increase range of motion in adult patients. In 2021, the Musculoskeletal Institute was awarded the Value-Based Health Care Prize in recognition of their success in improving patient outcomes using the 360-degree care model. This award recognizes inspiring initiatives that have adopted a fundamentally new line of thinking in creating excellent patient value in terms of real outcomes and real costs. And in 2020, the Musculoskeletal Institute was recognized with a Silver Award in the Musculoskeletal Management Category by the Validation Institute’s Health Value Awards for demonstrating measurably better and more transparent health outcomes, costs, and safety than conventional care.
What does this method of care delivery look like? Here’s a direct comparison of one model vs. the other.
In practice it looks like an interdisciplinary, coordinated approach to delivering great care where multiple specialists come together under one roof. It’s a team that includes care to right-size each person’s needs: orthopedic surgeons, sports medicine physicians, physiatrists, physical therapists, chiropractors, nurse practitioners, dietitians, social workers, and more, who work together to help people get back to the things that matter most. Treatment may include nonsurgical interventions, such as lifestyle modifications, physical therapy, or medication and injections, or surgery may be the best course of action to help improve pain and function. But they don’t start there unless it’s warranted.
It also requires measuring outcomes that are important to people, such as quality of life and pain over time, plus an understanding of the true cost of delivering care. With this knowledge of outcomes and cost, we can be more equipped to reward care providers for delivering better value while minimizing risk.
So what does good look like? Better care per dollar spent.
And from here on my couch, that sounds darn good.
